Arterial abnormalities and associated variations of the vertebrobasilar system on the brain base: apropos of a rare case / Anomalías arteriales y variaciones asociadas del sistema vertebrobasilar en la base del cerebro: un caso raro

SUMMARY: The presented case characterizes an association of primitive and definitive arteries with variations on the cadaveric brain base of a very old man. This case is found by the retrospective review of the data archive obtained during many years of cooperation of the author and co-authors. Fenestration of the (ectatic) basilar artery, partial and total duplication of some cerebellar arteries was associated with other variations of the vertebrobasilar and carotid systems. Although this is a case autopsied because of the myocardial infarction, the peculiarity of the case lies in the absence of the aneurysm based on the fenestration or dissection of one of the cerebral arteries.

RESUMEN: El caso presentado caracteriza una asociación de arterias primitivas y definitivas con variaciones sobre la base cerebral cadavérica de un anciano. Este caso se encuentra mediante la revisión retrospectiva de datos obtenidos durante muchos años de un trabajo de cooperación del autor y coautores. La fenestración de la arteria basilar (ectásica), la duplicación parcial y total de algunas arterias cerebelosas se asoció con otras variaciones de los sistemas vertebrobasilar y carotídeo. Si bien se trata de un caso de autopsia a causa de un infarto del miocardio, la peculiaridad del caso radica en la ausencia del aneurisma en base a la fenestración o disección de una de las arterias cerebrales.

Accidente cerebrovascular de la arteria basilar: cannabis como factor de riesgo en jóvenes / Cerebrovascular accident of basilar artery: Cannabis as a risk factor in young people / Acidente Vascular Cerebral (AVC) da artéria basilar: cannabis como fator de risco em jovens

Introducción. La arteria basilar se forma de las arterias vertebrales, cursa sobre el puente y se bifurca originando las arterias cerebrales posteriores. Irriga parte del tronco encefálico, cerebelo, tálamo y los lóbulos occipitales y temporales cerebrales. Su obstrucción es rara (1% de los accidentes isquémicos), puede ocurrir en cualquier parte de su trayecto, con cuadro clínico diverso. En jóvenes se añaden otros factores de riesgo distintos a los cardiovasculares, se incluye el consumo de sustancias psicoactivas. El objetivo de este artículo es presentar el caso de un adulto joven, su evolución posterior a la intervención endovascular y la asociación, pasada por alto, al consumo de cannabinoides. Caso clínico. Individuo de 23 años con 14 horas de parálisis facial periférica derecha, diplopía, disartria, hemiparesia e hiperreflexia izquierda, disfagia, náuseas y emesis. Tomografía Axial Computarizada de cráneo simple sin alteraciones. Posteriormente, al realizarse resonancia magnética nuclear, se evidencia isquemia pontomesencefálica y focos isquémicos agudos lacunares en lóbulos cerebelosos. Se consideró comprometido el territorio de la arteria basilar, por lo que se realizó angiotomografía que evidenció una obstrucción crítica de dicho vaso a nivel del tercio distal. Se realizó trombectomía con stent-retriever con recanalización total de la arteria basilar con flujo en toda su extensión. Al egreso fue clasificado como TOAST idiopático. Conclusiones. Las escalas etiológicas para stroke creadas para adultos mayores sobreestiman la etiología idiopática en pacientes jóvenes, lo cual puede ocasionar que el consumo de cannabis sea pasado por alto como causante pese a la asociación reportada por la literatura.

Introduction. The basilar artery is formed from the vertebral arteries, runs over the pons and bifurcates, originating the posterior cerebral arteries. It irrigates part of the brainstem, cerebellum, thalamus, and the occipital and temporal lobes of the brain. Its obstruction is rare (1% of ischemic accidents), it can occur in any part of its path, with a diverse clinical condition. In young people, other risk factors other than cardiovascular ones are added; psychoactive substance use is included. The objective of this article is to present the case of a young adult, his evolution after endovascular intervention and the association, overlooked, to the consumption of cannabinoids. Clinical case. 23-year-old man with 14 hours of right peripheral facial paralysis, diplopia, dysarthria, left hyperreflexia and hemiparesis, dysphagia, nausea and emesis. Simple skull Computerized Axial Tomography without alterations. Subsequently, when a nuclear magnetic resonance was performed, pontomesencephalic ischemia and acute lacunar ischemic foci in the cerebellar lobes were evidenced. The basilar artery territory was considered compromised, so a CT angiography was performed, which revealed a critical obstruction of said artery at the level of the distal third. A stent-retriever thrombectomy was performed with total recanalization of the basilar artery with flow in its entirety. Upon discharge, he was classified as "idiopathic" according to the TOAST classification. Conclusions. The etiological scales for stroke created for older adults overestimate idiopathic etiology in young patients, which may cause cannabis use to be overlooked as a cause despite the association reported in the literature.

Introdução. A artéria basilar é formada pelas artérias vertebrais, passa pela ponte e se bifurca, originando as artérias cerebrais posteriores. Irriga parte do tronco cerebral, cerebelo, tálamo e os lobos occipital e temporal do cérebro. Sua obstrução é rara (1% dos acidentes isquêmicos), podendo ocorrer em qualquer parte de seu trajeto, com quadro clínico diverso. Nos jovens, são adicionados outros fatores de risco além dos cardiovasculares, incluindo o consumo de substâncias psicoativas. O objetivo deste artigo é apresentar o caso de um adulto jovem, sua evolução após a intervenção endovascular e a associação, despercebida, ao consumo de canabinoides. Caso clínico. Indivíduo de 23 anos com 14 horas de paralisia facial periférica direita, diplopia, disartria, hemiparesia e hiperreflexia esquerda, disfagia, náuseas e vômitos. Tomografia axial computadorizada de crânio simples sem alterações. Posteriormente, quando foi realizada a ressonância magnética nuclear, foram evidenciados isquemia pontomesencefálica e focos agudos de isquemia lacunar nos lobos cerebelares. O território da artéria basilar foi considerado comprometido, por isso foi realizada uma angiotomografia, que revelou uma obstrução crítica do referido vaso no terço distal. Foi realizada trombectomia stent-retriever com recanalização total da artéria basilar com fluxo em sua totalidade. No momento da alta, foi classificado como TOAST idiopática. Conclusões.As escalas etiológicas para AVC criadas para idosos superestimam a etiologia idiopática em pacientes jovens, o que pode fazer com que o uso de cannabis seja negligenciado como causa, apesar da associação relatada na literatura.

Basilar artery dolichoectasia an unusual and rare cause of secondary trigeminal neuralgia: a clinical report / Dolicoectasia da artéria basilar uma causa incomum e rara de neuralgia do trigêmeo secundária: um relato clínico

Objective: Patients with Trigeminal Neuralgia often consults a dentist for relief of their symptoms as the pain seems to be arising from teeth and allied oral structures. Basilar artery Dolichoectasia is an unusual and very rare cause of secondary Trigeminal Neuralgia as it compresses the Trigeminal nerve Root Entry Zone. Case reports: We report three cases of Trigeminal Neuralgia caused by Basilar artery Dolichoectasia compression. The corneal reflex was found absent in all three of the cases along with mild neurological deficits in one case. Multiplanar T1/T2W images through the brain disclosed an aberrant, cirsoid (S-shaped) and torturous Dolichoectasia of basilar artery offending the Trigeminal nerve Root Entry Zone. Discussion:Based on these findings we propose a protocol for general dentist for diagnosis of patients with trigeminal neuralgia and timely exclusion of secondary intracranial causes. Conclusion: General dentists and oral surgeons ought to consider this diagnosis in patients presenting with chronic facial pain especially pain mimicking neuralgia with loss of corneal reflex or other neurosensory deficit on the face along with nighttime pain episodes. Timely and accurate diagnosis and prompt referral to a concerned specialist can have an enormous impact on patient survival rate in such cases (AU)

Objetivo: Pacientes com Neuralgia do Trigêmeo frequentemente consultam um dentista para alívio de seus sintomas visto que a dor parece surgir dos dentes e estruturas orais relacionadas. A Dolicoectasia da artéria basilar é uma causa incomum e muito rara de Neuralgia do Trigêmeo secundária, pois comprime a zona de entrada da raiz do nervo trigêmeo. Relatos de casos: Relatamos três casos de Neuralgia do Trigêmeo causada por compressão por Dolicoectasia da artéria basilar. O reflexo da córnea se encontrava ausente em todos os três casos, juntamente com leves déficits neurológicos em um caso. Imagens multiplanares T1/T2W através do cérebro revelaram uma Dolicoectasia cirsóide (em forma de S) anômala e tortuosa da artéria basilar que atingiu a zona de entrada da raiz do nervo trigêmeo. Discussão: Com base nesses achados, propomos para o dentista clínico-geral um protocolo para diagnóstico de pacientes com Neuralgia do Trigêmeo e exclusão oportuna de causas intracranianas secundárias. Conclusão: Os dentistas clínicos-gerais e cirurgiões orais devem considerar este diagnóstico em pacientes que apresentam dor facial crônica, especialmente dor que mimetiza neuralgia com perda do reflexo da córnea ou outro déficit neurossensorial na face junto com episódios de dor noturna. O diagnóstico oportuno e preciso e o encaminhamento imediato a um especialista em questão podem ter um enorme impacto na taxa de sobrevida do paciente em tais casos (AU)

Characteristics of high-resolution magnetic resonance vessel wall imaging of cervicocerebral artery dissection and the influential factors of vascular recanalization / 中南大学学报(医学版)

OBJECTIVES@#Cervicocerebral artery dissection (CAD) is one of the important causes for ischemic stroke in young and middle-aged people. CAD is dangerous and untimely diagnosis and treatment are likely to result in severe disability. Early diagnosis and timely intervention can greatly improve the prognosis of patients. This study was to investigate the imaging features of CAD on high-resolution magnetic resonance vessel wall imaging (HRMR-VWI) and to analyze the influential factors of vascular recanalization.@*METHODS@#A total of 19 CAD patients with both baseline HRMR-VWI and follow-up data of vascular imaging in the period from April 2017 to December 2019 in Department of Radiology, Xiangya Hospital, Central South University were retrospectively analyzed. The diseased vessels were divided into a recovery group and a unrecovered group. After treatment, diseased vessels with no residual arterial dissection and no residual stenosis in the lumen were included in the recovery group. Diseased vessels with stenosis, occlusion or residual dissection were included in the unrecovered group. Diseased vessels were divided into a ischemic stroke group and a non-ischemic stroke group according to the presence or absence of ischemic stroke in the area supplied by the diseased vessels. Differences in clinical data and HRMR-VWI imaging findings were compared between the groups.@*RESULTS@#A total of 26 vessels were involved, including 14 (53.8%) internal carotid artery extracranial segment, 8 (30.8%) vertebral artery extracranial segment, 3 (11.5%) vertebral artery intracranial segment, and 1 (3.9%) basilar artery. Ischemic stroke occurred in 16 diseased vascular supply areas. Intramural hematoma was all observed in the baseline HMR-VWI of the affected vessels. There were 18 vessels (69.2%) in the recovery group and 8 vessels (30.8%) in the unrecovered group. Compared with the vessels in the recovery group, the vessels in the unrecovered group were mostly found in the intracranial segment (@*CONCLUSIONS@#Intramural hematoma is a common imaging manifestation of CAD and can be shown clearly and accurately on HRMR-VWI. Recanalization rate of CAD is high, and the recanalization of CAD in intracranial segment is slower than that of CAD in extracranial segment, which can prolong the review time.

Systematization, distribution, and territories of the caudal cerebral artery on the surface of the brain in nutria (Myocastor coypus) / Sistematização, distribuição e territórios da artéria cerebral caudal na superfície do cérebro em Nutria (Myocastor coypus)

The nutria (Myocastor coypus) is a medium-sized, semi-aquatic rodent valued by the skin and meat industry. This study aimed to describe and systematize the caudal cerebral artery on the brain surface in nutria, establishing a standard model and its main variations in this species. The thirty animals used were euthanized according to animal welfare rules. The vessels were filled with latex stained with red pigment and the samples were fixed in formaldehyde. In nutria, the brain was vascularized by the vertebral basilar system. The terminal branches of the basilar artery originated the rostral cerebellar, caudal cerebral, rostral choroidal and middle cerebral arteries, and its terminal branch, the rostral cerebral artery. The terminal branch of the basilar artery projected the caudal cerebral artery, which is usually a single medium-caliber vessel, into the transverse fissure of the brain. The caudal cerebral artery was presented as a single (66.7% of the cases to the right and 76.7% to the left) and double vessel (33.3% of the cases to the right and 23.3% to the left). It originated the rostral mesencephalic artery, the proximal component, and the caudal inter-hemispheric artery. The terminal branches of the rostral and caudal tectal mesencephalic arteries formed a typical anastomotic network. The caudal inter-hemispheric artery emitted central branches, the caudal choroidal artery, hemispherical occipital arteries, rostral tectal mesencephalic branches and distal components, and anastomosed "in osculum" with the terminal branches of the rostral inter-hemispheric artery. The caudal choroidal artery anastomosed with the rostral choroidal artery, where it branched out on the thalamic mass, vascularizing all diencephalic structures and the hippocampus. The caudal cerebral artery and its terminal branches anastomosed with the terminal branches of the rostral and middle cerebral arteries in a restricted region of the caudal pole of the cerebral hemisphere. The vascularization area of the caudal cerebral artery and its central branches in the paleopallial of the piriform lobe is extremely restricted, caudomedially.(AU)

A nutria (Myocastor coypus) é um roedor semi-aquático de tamanho mediano, apreciado na indústria de peles e carne. Este trabalho tem por objetivo descrever e sistematizar a artéria cerebral caudal na superfície do cérebro em nutria, estabelecendo um modelo padrão e suas principais variações e territórios nesta espécie. Os trinta animais utilizados foram eutanasiados segundo as regras de bem-estar animal, os vasos foram preenchidos com látex, corado em vermelho e as peças foram fixadas em formoldeído. O cérebro foi vascularizado exclusivamente pelo sistema vértebro-basilar. Os ramos terminais da artéria basilar originaram as artérias cerebelar rostral, cerebral caudal, corióidea rostral, cerebral média e seu ramo terminal, a artéria cerebral rostral. O ramo terminal da artéria basilar lançou a artéria cerebral caudal, um vaso normalmente único, de médio calibre, para o interior da fissura transversa do cérebro. A artéria cerebral caudal foi um vaso único em 66,7% à direita e em 76,7% à esquerda e mostrou-se dupla em 33,3% à direita e em 23,3% à esquerda. Ela lançou a artéria tectal mesencefálica rostral, componente proximal e a artéria inter-hemisférica caudal. Os ramos terminais das artérias tectais mesencefálicas, rostral e caudal, formavam uma rede anastomótica típica. A artéria inter-hemisférica caudal lançou ramos centrais, a artéria corióidea caudal, as artérias hemisféricas occipitais, os ramos tectais mesencefálicos rostrais, componentes distais e anastomosou-se "em ósculo" com o ramo terminal da artéria inter-hemisférica rostral. A artéria corióidea caudal anastomosava-se com a artéria corióidea rostral, onde ramificavam-se sobre a massa talâmica, vascularizando todas as estruturas do diencéfalo e hipocampo. A artéria cerebral caudal com seus ramos terminais apresenta anastomoses com os ramos terminais das artérias cerebrais rostral e média em uma região restrita do pólo caudal do hemisfério cerebral. A área de vascularização da artéria cerebral caudal com seus ramos centrais no páleo-palio do lobo piriforme é extremamente restrita, caudo-medialmente ao mesmo.(AU)

Magnetic resonance angiography and transcranial Doppler ultrasound findings in patients with a clinical diagnosis of vertebrobasilar insufficiency

OBJECTIVE: To evaluate the findings of magnetic resonance angiography (MRA) and transcranial Doppler ultrasound (TCD) in patients with a clinical diagnosis of vertebrobasilar insufficiency (VBI). METHOD: From our outpatient neurotology clinic, we selected patients (using the criteria proposed by Grad and Baloh) with a clinical diagnosis of VBI. We excluded patients with any definite cause for vestibular symptoms, a noncontrolled metabolic disease or any contraindication to MRA or TCD. The patients in the study group were sex- and age-matched with subjects who did not have vestibular symptoms (control group). Our final group of patients included 24 patients (study, n=12; control, n=12). RESULTS: The MRA results did not demonstrate significant differences in the findings between our study and control groups. TCD demonstrated that the systolic pulse velocity of the right middle cerebral artery, end diastolic velocity of the basilar artery, pulsatility index (PI) of the left middle cerebral artery, PI of the right middle cerebral artery, and PI of the basilar artery were significantly higher in the study group than in the control group, suggesting abnormalities affecting the microcirculation of patients with a clinical diagnosis of VBI compared with controls. CONCLUSION: MRA failed to reveal abnormalities in patients with a clinical diagnosis of VBI compared with controls. The PI of the basilar artery, measured using TCD, demonstrated high sensitivity (91%) and specificity (91%) for detecting clinically diagnosed VBI.

Terapia endovascular de la trombosis de arteria basilar: reporte de 2 casos / Endovascular therapy of basilar artery thrombosis: 2 case report

Resumen Los eventos cerebrovasculares afectan el territorio de la circulación posterior pueden tener un comportamiento benigno,sin embargo, la oclusión de la arteria basilar suele tener consecuencias devastadoras. El uso de trombolísis sistémica ointra-arterial y la terapia endovascular son opciones terapéuticas con recuperación funcional apropiada. Se reportan doscasos de trombosis arterial basilar cuyo diagnóstico temprano permitió un manejo combinado entre embolectomía endovasculary trombólisis con resultados adecuados.

Abstract Stroke of the posterior cerebral circulation may have a benign course but basilar artery thrombosis usually have devastating consequences. Systemic thrombolysis and endovascular treatment are promising options with appropriate functional outcomes. We report two cases of basilar artery thrombosis in which early diagnosis and treatment with endovascular embolectomy and thrombolysis showed good results.

Microvascular Compressicaude by Slinging a Tortuous Vertebrobasilar Artery to the Petrous Dura in Hemifacial Spasm: Technical Note

Objective In cases of hemifacial spasm caused by a tortuous vertebrobasilar artery (TVBA), the traditional treatment technique involves Teflon (polytetrafluoroethylene), which can be ineffective and fraught with recurrence and neurological complications. In such cases, there are various techniques of arteriopexy using adhesive compositions, 'suspending loops' made of synthetic materials, dural or fascial flaps, surgical sutures passed around or through the vascular adventitia, as well as fenestrated aneurysmal clips. In the present paper, we describe a new technique of slinging the vertebral artery (VA) to the petrous dura for microvascular decompression (MVD) in a patient with hemifacial spasm caused by a TVBA. Method A 50-year-old taxi driver presented with a left-sided severe hemifacial spasm. A magnetic resonance imaging (MRI) scan of the brain showed a large tortuous left-sided vertebral artery impinging and compressing the exit/entry zone of the 7th and 8th nerve complex. After a craniotomy, a TVBAwas found impinging and compressing the entry zone of the 7th and 8th nerve complex. Arachnoid bands attaching the artery to the nerve complex and the pons were released by sharp microdissection. Through the upper part of the incision, a 2.5 1 cmtemporal fascia free flap was harvested. After the fixation of the free flap, a 6­0 prolene suture was passed through its length several times using the traditional Bengali sewing and stitching techniques to make embroidered quilts called Nakshi katha. The'prolenated' fascia was passed around the compressing portion of the VA. Both ends of the fascia were brought together and stitched to the posterior petrous dura to keep the TVBA away from the 7th and 8th nerves and the pons. Result The patient had no hemifacial spasm immediately after the recovery from the anesthesia. A postoperative MRI of the brain showed that the VA was away from the entry zone of the 7th and 8th nerves.

Arteritis de células gigantes en el sistema vertebrobasilar, isquemias cerebelo-occipitales y parálisis III par: caso clínico / Giant cell arteritis of the vertebrobasilar system, posterior ischemia and palsy of the third nerve: report of one case

Giant cell arteritis is the most common vasculitis in patients aged over 50 years. We report an 89-year-old woman with significant weight loss and persistent frontal-occipital headaches lasting two months. The neurological examination at admission identified a decrease in visual acuity of the left eye, paralysis of the third cranial nerve of the right eye and alterations of body motility without objective signs of damage of the motor or sensitive pathways. Magnetic resonance imaging showed changes of the temporal artery wall and in both vertebral arteries, as well as bilateral cerebellar and occipital ischemic lesions. The Doppler ultrasound of the temporal arteries was compatible with Giant cell arteritis. Treatment with steroids was started. While receiving oral prednisone, the patient suffered new infarcts of the posterior territory, documented with a CAT scan.

Geometric features of vertebrobasilar arterial system in adult black Kenyans / Características geométricas del sistema arterial vertebrobasilar en kenianos negros adultos

Geometric features of vertebrobasilar system influence occurrence of posterior circulation atherosclerosis, aneurysms, stroke and neuroradiological procedures. These features show ethnic variation, but data from black Africans in Sub Saharan Africa are scarce. This study aimed to describe geometric features of vertebrobasilar system in a black Kenyan population. It was a descriptive cadaveric study at Department of Human Anatomy, University of Nairobi. One hundred and seventy three formalin-fixed adult brains of individuals (99 male; 74 female; Age range 20 - 79) who had died of non cerebrovascular causes were studied. Level and angle of confluence of vertebral artery; diameter, length and bifurcation angles of basilar artery were measured. Data were analysed by SPSS version 21 for windows. The student t - test was used to determine the sex differences at 95 % confidence interval. Data are presented in macrographs, tables and bar charts. Confluence of vertebral arteries occurred at the sulcus bulbopontinus in 79.8 %; rostral to it in 11.5 % and caudal to it in 8.7 % of cases. Mean angle of vertebral artery confluence was 46.7º and 68.9º in males and females respectively (p£0.042). Mean length of the basilar artery was 26.8 mm; 26.3 mm in males and 27.1 mm in females (p=0.465). Mean diameter was 3.52 mm; 3.32 mm in males and 3.72 mm in females (p=0.002). The mean angle of basilar artery bifurcation was 120.3º ± 15.2; 99.3º ± 32.9 in males and 140.3º ± 16.1 in females (p=0.024). It was wider than 90º in 82.9 % of males and 95.9 % females (p=0.032). In 85 (49.1 %) it was wider than 120º. The vertebrobasilar system in the Kenyan population has geometric features that constitute risk factors for atherosclerosis. These features display sex dimorphism which may explain differences in prevalence of atherosclerosis and aneurysms. Neurosurgeons and neurologists should be aware of these differences. Individuals with risk prone geometric features should be followed up for atherosclerosis.

Las características geométricas del sistema vertebrobasilar influyen en la aparición de aterosclerosis en la circulación posterior, aneurismas, apoplejía, detectados durante procedimientos neurorradiológicos. Estas características muestran variación étnica, pero los datos de los africanos negros en el África Subsahariana son escasos. Este estudio tuvo como objetivo describir las características geométricas del sistema vertebrobasilar en una población negra de Kenia. Fue un estudio descriptivo cadavérico en el Departamento de Anatomía Humana de la Universidad de Nairobi. Se estudiaron 173 cerebros adultos (99 varones, 74 mujeres, rango de edad 20-79), fijados en formalina, de individuos que habían fallecido por causas no cerebrovasculares. Se midieron el nivel y ángulo de confluencia de la arteria vertebral, diámetro, longitud y bifurcación de la arteria basilar. Los datos fueron analizados por SPSS versión 21 para Windows. La prueba t de Student se utilizó para determinar las diferencias de sexo con un intervalo de confianza del 95 %. Los datos se presentan en macrografías, tablas y gráficos de barras. La confluencia de las arterias vertebrales se produjo en el surco bulbopontino en el 79,8 %; rostral al surco en 11,5 % y caudal al surco en 8,7 % de los casos. El ángulo medio de la confluencia de la arteria vertebral fue 46,70 y 68,90 en hombres y mujeres, respectivamente (p£0,042). La longitud media de la arteria basilar fue de 26,8 mm; 26,3 mm en hombres y 27,1 mm en mujeres (p=0,465). El diámetro promedio fue de 3,52 mm; 3,32 mm en hombres y 3,72 mm en mujeres (p=0,002). El ángulo medio de la bifurcación de la arteria basilar fue de 120,30 ± 15,2; 99.30 ± 32,9 en hombres y 140,30 ± 16,1en mujeres (p=0,024). Era más amplio que 90º. En un 82,9 % de los hombres y 95,9 % de las mujeres (p=0,032) se observó un ángulo más amplio que 90°. En 85 (49,1 %) fue más amplio que 120°. El sistema vertebrobasilar en la población de Kenia tiene características geométricas que constituyen factores de riesgo para la aterosclerosis. Estas características muestran dimorfismo sexual que puede explicar las diferencias en la prevalencia de aterosclerosis y aneurismas. Los neurocirujanos y los neurólogos deben tener en cuenta estas diferencias. Las personas con características geométricas propensas al riesgo deben ser seguidas por aterosclerosis.

The history of basilar artery occlusion: when art aids science / História da oclusão da artéria basilar: quando a arte auxilia a ciência

ABSTRACT Basilar artery occlusion (BAO) ischemic stroke is a relatively rare condition with high morbidity and mortality rates. To date, the best acute reperfusion therapy for BAO has still not been established, mainly due to the lack of randomized controlled trials in this field. In this article, we review the history of BAO diagnosis and treatment, and the impact of modern technological resources on the clinical evolution and prognosis of BAO over time. Furthermore, we describe historical events and nonmedical literature descriptions related to BAO. We conclude that BAO is a singular example of how art may help medical sciences with accurate descriptions of medical conditions.

RESUMO O acidente vascular cerebral isquêmico secundário à oclusão aguda da basilar (OAB) é uma condição relativamente rara, que cursa com elevada morbimortalidade. Até o momento atual, a melhor estratégia de recanalização arterial na fase aguda da OAB não está definida, principalmente pela carência de ensaios clínicos randomizados e controlados neste contexto. Neste artigo, revisamos aspectos históricos do diagnóstico e do tratamento desta condição, assim como o impacto do avanço tecnológico na evolução clínica e prognóstico desta condição. Ademais, descrevemos fatos históricos e a literatura fictícia relacionados à OAB. Concluímos que a OAB é um exemplo peculiar de como a arte pode auxiliar a medicina na descrição acurada de condições médicas.

Basilar Artery Plaque and Pontine Infarction Location and Vascular Geometry / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Subclinical atherosclerotic plaques are common in patients with pontine infarctions (PIs) but without basilar artery (BA) stenosis. We hypothesized that BA plaque locations may differ by PI type and vertical location as well as vertebrobasilar artery geometry. METHODS: Ninety-six patients with PI but without BA stenosis on magnetic resonance imaging (MRI) and magnetic resonance angiography were enrolled. PIs were classified by type (paramedian, deep, or lateral) and vertical location (rostral, middle, or caudal). Patients underwent high-resolution MRI to evaluate BA plaque location (anterior, posterior, or lateral). The mid-BA angle on anteroposterior view and angle between the BA and dominant vertebral artery (BA-VA angle) on lateral view were measured. RESULTS: The PIs were paramedian (72.9%), deep (17.7%), and lateral (9.4%) type with a rostral (32.3%), middle (42.7%), and caudal (25.0%) vertical location. The BA plaque locations differed by PI type (P=0.03) and vertical location (P < 0.001); BA plaques were most frequent at the posterior wall in paramedian (37.1%) and caudal (58.3%) PIs and at the lateral wall in lateral (55.5%) and middle (34.1%) PIs. The BA-VA and mid-BA angles differed by BA plaque and PI vertical location; the greatest BA-VA angle was observed in patients with posterior plaques (P < 0.001) and caudal PIs (P<0.001). Greatest mid-BA angles were observed with lateral BA plaques (P=0.03) and middlelocated PIs (P=0.03). CONCLUSIONS: Greater mid-BA angulation may enhance lateral plaque formation, causing lateral and middle PIs, whereas greater BA-VA angulation may enhance posterior plaque formation, causing paramedian or caudal PIs.

Correlation of Adventitial Vasa Vasorum with Intracranial Atherosclerosis: A Postmortem Study / 대한뇌졸중학회지

BACKGROUND AND PURPOSE: Vasa vasorum (VV) have been believed to be rare or non-existent in small-caliber intracranial arteries. In a series of human cerebral artery specimens, we identified and examined the distribution of VV in association with co-existing intracranial atherosclerosis. METHODS: We obtained cerebral artery specimens from 32 consecutive autopsies of subjects aged 45 years or above. We scrutinized middle cerebral artery (MCA), vertebral artery (VA), and basilar artery (BA) for the presence of adventitial VV. We described the distribution of VV, and the characteristics of co-existing atherosclerotic lesions. RESULTS: Among 157 intracranial arteries, adventitial VV were present in 74 of the 157 specimens (47%), involving MCA (n=13, 18%), BA (n=14, 19%), and VA (n=47, 64%). Although qualitatively these 74 adventitial VV distributed similarly in arteries with or without atherosclerotic lesions (disease-free arteries n=4/8; arteries of pre-atherosclerosis n=17/42; and arteries of progressive atherosclerosis n=53/107), the presence of adventitial VV in intracranial VA was associated with a heavier plaque load (1.72±1.66 mm2 vs. 0.40±0.32 mm2, P < 0.001), severer luminal stenosis (25%±21% vs. 12%±9%, P=0.002), higher rate of concentric lesions (79% vs. 36%, P=0.002), and denser intraplaque calcification (44% vs. 0%, P=0.003). Histologically, intracranial VA with VV had a larger diameter (3.40±0.79 mm vs. 2.34±0.58 mm, P < 0.001), thicker arterial wall (0.31±0.13 mm vs. 0.23±0.06 mm, P=0.002), and a larger intima-media (0.19±0.09 mm vs. 0.13± 0.04 mm, P=0.003) than VA without VV. CONCLUSIONS: Our study demonstrated the distribution of adventitial VV within brain vasculature and association between vertebral VV and progressive atherosclerotic lesions with a heavier plaque load and denser intraplaque calcification.

Implications of Mechanical Endovascular Thrombectomy for Acute Basilar and Posterior Cerebral Artery Occlusion

OBJECTIVE: Protocols for posterior circulation ischemic stroke have not been established by randomized clinical trials. Mechanical endovascular thrombectomy (MET) devices are evolving, and many of these devices already developed or in development are suitable for posterior circulation MET. MATERIALS AND METHODS: We investigated the medical records of patients who underwent MET for posterior circulation ischemic stroke from January 2012 to August 2016. Fifteen patients were included. MET was performed in patients with or without injected intravenous tissue plasminogen activator. MET was considered in patients with a National Institute of Health Stroke Scale score of 4 or more, older than 18 years, with definite occlusion of the basilar artery or posterior cerebral artery (PCA), and who arrived at the hospital within 24 hours from onset. RESULTS: The direct catheter aspiration technique was used in five cases, and the stent retrieval technique was used in seven cases. The stent retrieval technique with the direct aspiration technique was used in three cases. Recanalization failed in two cases. Basilar occlusion without PCA involvement is the only effective factor of successful recanalization (p = 0.03). Successful recanalization (p = 0.005) and the presence of a posterior communicating artery (p = 0.005) affected the good outcome at discharge. CONCLUSION: An early diagnosis and active MET may improve the patient outcome. MET may help recanalization and good flow restoration and the potential for a good outcome.

First Human Evaluation of Endothelial Healing after a Pipeline Flex Embolization Device with Shield Technology Implanted in Posterior Circulation Using Optical Coherence Tomography / 신경중재치료의학

A 64-year-old female presented with an incidentally-discovered right posterior inferior cerebral artery (PICA) aneurysm, initially treated in 2015 by simple coiling. Follow-up demonstrated significant coil compaction that required retreatment. Retreatment was done uneventfully using a Pipeline embolization device (PED) shield deployed starting from the basilar artery and ending at the V4 segment of the vertebral artery. Eight-weeks post-deployment, a follow-up digital subtraction imaging (DSA) and intravascular imaging with optical coherence tomography were obtained. The intravascular imaging demonstrated that the flow diverter had good wall apposition and concentric neointimal growth over the braid with exception to the areas that the PED was not in contact with the endothelial wall, such as at the right PICA ostium and at the vertebrobasilar junction. The entire procedure was safe, and the patient had no complications. In this article, we describe for the first time the assessment of the status of endothelial “healing” of the PED shield at 8-weeks.

Spontaneous Basilar Artery Dissection: A Case Report and Literature Review

Spontaneous basilar artery dissection is a rare condition and a diagnostic challenge with a high potential for morbidity and mortality if untreated. It has an estimated incidence of 1 to 1.5 cases per 100,000 people. Few cases have been described in the literature up to the present day. The clinical outcomes, prognosis and treatment remain uncertain. The authors report the rare case of a 55-year-old female patient who presented to the Interventional Neuroradiology service at Hospital São Marcos, Teresina, in the state of Piauí, Brazil, with a history of severe headache located in the occipital region and in the nape with no improvement using common analgesics. A magnetic resonance imaging of the brain showed a saccular dilatation in the basilar artery, and a digital cerebral angiography showed a basilar artery dissection associated with a dissecting aneurysm.

Tratamiento endovascular de aneurisma disecante de la arteria basilar con dispositivo redireccionador de flujo FRED: primer reporte de caso en Colombia / Basilar dissecting aneurysm successfully treated by FRED Flow-Diverter device: first case report in Colombia

RESUMEN INTRODUCCIÓN: Los aneurismas disecantes de la arteria basilar tienen un curso clínico impredecible que, eventualmente, evoluciona a un accidente cerebrovascular hemorrágico o isquémico grave. Por otro lado, su abordaje terapéutico es controvertido y no existen líneas claras de tratamiento. CASO CLÍNICO: Presentamos el caso de una mujer de 28 años con un infarto del tallo cerebral secundario a aneurisma disecante de la arteria basilar, tratado exitosamente con dispositivo endoluminal redireccionador de flujo (FRED). CONCLUSIÓN: El tratamiento endovascular con FRED de los aneurismas disecantes parece ofrecer ventajas sobre las técnicas quirúrgicas abiertas y stents tradicionales, en casos seleccionados.

SUMMARY INTRODUCTION. Dissecting basilar artery aneurysms have an unpredictable course, eventually evolving to serious hemorrhagic or ischemic stroke; on the other hand, its therapeutic approach in controversial and there are no clear lines of treatment. CASE REPORT. We report a case of a 28-year-old female with brain stem infarction secondary to basilar dissecting aneurysm successfully treated by Flow-Redirection Endoluminal Device (FRED). CONCLUSION. Endovascular treatment of dissecting basilar artery aneurysms with FRED seems to offer advantages over traditional open surgical techniques and conventional stents in selected cases.

Management of Recurrent Cerebral Aneurysm after Surgical Clipping : Clinical Article

OBJECTIVE: Surgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them.METHODS: From January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed.RESULTS: All recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge.CONCLUSION: This study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.

Management of Recurrent Cerebral Aneurysm after Surgical Clipping : Clinical Article

OBJECTIVE: Surgical clipping of the cerebral aenurysm is considered as a standard therapy with endovascular coil embolization. The surgical clipping is known to be superior to the endovascular coil embolization in terms of recurrent rate. However, a recurrent aneurysm which is initially treated by surgical clipping is difficult to handle. The purpose of this study was to research the management of the recurrent cerebral aneurysm after a surgical clipping and how to overcome them. METHODS: From January 1996 to December 2015, medical records and radiologic findings of 14 patients with recurrent aneurysm after surgical clipping were reviewed retrospectively. Detailed case-by-case analysis was performed based on preoperative, postoperative and follow-up radiologic examinations and operative findings. All clinical variables including age, sex, aneurysm size and location, type and number of applied clips, prognosis, and time to recurrence are evaluated. All patients are classified by causes of the recurrence. Possible risk factors that could contribute to those causes and overcoming ways are comprehensively discussed. RESULTS: All recurrent aneurysms after surgical clipping were 14 of 2364 (0.5%). Three cases were males and 11 cases were females. Mean age was 52.3. At first treatment, nine cases were ruptured aneurysms, four cases were unruptured aneurysms, and one case was unknown. Locations of recurrent aneurysm were determined; anterior communicating artery (A-com) (n=7), posterior communicating artery (P-com) (n=3), middle cerebral artery (n=2), anterior cerebral artery (n=1) and basilar artery (n=1). As treatment of the recurrence, 11 cases were treated by surgical clipping and three cases were treated by endovascular coil embolization. Three cases of all 14 cases occurred in a month after the initial treatment. Eleven cases occurred after a longer interval, and three of them occurred after 15 years. By analyzing radiographs and operative findings, several main causes of the recurrent cerebral aneurysm were found. One case was incomplete clipping, five cases were clip slippage, and eight cases were fragility of vessel wall near the clip edge. CONCLUSION: This study revealed main causes of the recurrent aneurysm and contributing risk factors to be controlled. To manage those risk factors and ultimately prevent the recurrent aneurysm, neurosurgeons have to be careful in the technical aspect during surgery for a complete clipping without a slippage. Even in a perfect surgery, an aneurysm may recur at the clip site due to a hemodynamic change over years. Therefore, all patients must be followed up by imaging for a long period of time.